International Statistical Classification of Diseases and ... CARINFONET.pdf · 7 ICD-11 intro / 3rd CARINFONET Steering Group Meeting / Tashkent, Uzbekistan, 18 –20 June 2019 International

International Statistical Classification of Diseases and

Related Health Problems, 11th Revision (ICD-11)

Nenad Friedrich Ivan KostanjsekClassifications, Terminologies and Standards TeamDivision of Data, Analytics, and Delivery for Impact

email: [email protected]

Third meeting of the CARINFONET Steering Group,Tashkent, Uzbekistan, 18 – 20 June 2019

mailto:[email protected]

2 ICD-11 intro / 3rd CARINFONET Steering Group Meeting / Tashkent, Uzbekistan, 18 – 20 June 2019

Overview

Why ICD-11?

What is new in ICD-11?

– Content

– Architecture

– Tooling environment

Implementing ICD-11

Other WHO-FIC: ICF & ICHI


Global number of deaths by registration and reporting status to WHO

57

2720

16 14

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Deaths Registered Reported toWHO's

mortalitydatabase, any

Reported toWHO, by ICD

code

Reported toWHO,

detailedlisting & non-

garbagePreliminary estimates, WHO, 2016


ICD-10 implementation problems

CURRENT State CURRENT ImpactHigh Income Countries:

• Proliferation of ICD-10 country modifications

• Formulation of national coding dictionaries and rules

Low & Middle-Income Countries:

• Poor uptake & implementation of ICD

Translations are done manually by individuals

Expensive expert-based training

Undermining international data comparability

Duplicated efforts and increased complexity of national

dictionaries and rules, no enrichment of international index and

rules

Lack of accurate disease information in countries with highest

disease burden (information paradox)

Delayed implementation

Lack of terminological consistency, time consuming

management and QA of translations

Quality of coded data compromised by coding errors despite

expensive expert coder training


ICD-10 Problems related to update, maintenance dissemination

CURRENT State CURRENT ImpactManual curation. Updating and dissemination of ICD-10 is

carried out in a manual fashion with individual text files

Poor and time-consuming implementation of updates

ICD-10 is disseminated as book (i.e. information product)

ICD users in LIC can’t afford purchase of ICD Books

ICD categories lack a unique identifier

Difficult & delayed integration of ICD in electronic health record

systems and other software.

Increased software development time (poor time to market

ratio)

Loss of data international data comparability as ICD users in LIC

create their own shortlist and update list

Ambiguous referencing of ICD categories


Why ICD-11?

Up-to-date scientific knowledge – statistical continuity

Serving multiple use case (mortality & morbidity statistics, health care cost, primary care, quality and safety, progress towards SDGs, clinical documentation, research)

Improve usabilityEnable coding of more clinical detail – code combinationsEasy access & less expensive training

Make eHealth ready for use in electronic environments – not just a print product

Linkages to other relevant classifications/ terminologies (ICD-O, ICPC, ICECI, ICF, SNOMED-CT, ATC, INN, eML etc.)

Full multilingual support on translation and output


International Classification of Diseases (ICD) Use Cases

Scientific consensus of clinical phenotype

Public Health Surveillance

– Mortality (i.e. cause-of-death registration)

– Morbidity (i.e. Hospital based tabulation of main condition)

Case based data aggregation

– Generate and document diagnosis in different settings (inpatient, primary care)

– Casemix information for reimbursement & resource allocation

– Quality and safety (e.g. adverse event reporting, quality of care)

– Research (GBD, clinical trials)

Statistics tool

Clinical tool

Administrative tool


Timeline

2007 Start ICD-11 revision

…

2018 June release of version for implementation

2019 May Adopted by 72nd World Health Assembly


ICD-11 Scientific clinical input

Extensive participation by national and international scientific societies

Over 300 clinical specialists organized in 30 topic advisory groups, 270 Institutions, 55 countries

Input from clinical modifications of old ICD-10 – and they were based on clinical needs

Reviews, testing, commenting => 99 countries


ICD-11 changes from ICD-10 – major examples

Influenza moved to infectious diseases (Chap. 1)

Neoplasms include morphology; brain and haematological tumours outside old benign/malignant scheme

Antimicrobial resistance codes added- essentially missing in ICD-10

HIV subdivisions added- outdated detail in ICD-10

Skin cancer - melanoma types missing – basalioma missing in ICD-10

Upper and lower respiratory tract infections structured more clearly

Diabetes coding clinically more relevant and flexible

Postoperative complications

– in body system chapters only for permanent conditions, no residuals

– Acute complications code with injury, mode, mechanism (external causes)

In general: more relevant and up-to-date clinical detail


ICD-11 Classification System for coding Quality & Safety Events


A clinical example - device

A respirator malfunction causes a barotrauma with air embolism in a patient

Coding:

PK9C.1& XD4M09 Cause of harm (medical devices associated with injury or harm & Ventilator, Adult)

PL12.1 Mode/mechanism (Functional device failure)

NF0A.0 Harm (Air embolism, traumatic)


Special Topic gaming disorder

Only for very serious cases

– impaired control over gaming

– increasing priority given to gaming - takes precedence over other life interests and daily activities;

– continuation or escalation of gaming despite the occurrence of negative consequences.

– over a period of at least 12 months

.


Special topic: Diagnoses in Traditional medicine

Supplementary chapter, optional use

Only diagnoses -- NO THERAPY !!!

Use code in addition to the codes of the regular chapters

Current module

– relating to ancient Chinese medicine as practiced in Korea, Japan, China and other countries around the world.

– Represents a union set dreived from national standards or ICD-10 U codes

Other modules for diagnoses in traditional medicine may follow


1. ICD Concept Title2. Hierarchy, Type and Use

a)Parentsb)Typec)Use

3. Textual Definition(s)a) Description (short)b) Definition (long)

4. Termsa) Index Terms

1. Synonyms2. Inclusion Terms

b) Exclusion Terms

5. Clinical Descriptiona) Body System(s) b) Body Part(s)[Anatomical Site(s)]c) Manifestation Properties

a) Signs & Symptoms b) Findings

d) Causal Propertiese) Etiology Type

a) Infection (agents)b) Injury (mechanisms)

f) Risk Factorsg) Genomic Characteristicsh) Temporal Propertiesi) Severity Propertiesj) Functional Propertiesk) Specific Condition Propertiesl) Treatment Propertiesm) Diagnostic Criteria

ICD-11 Content model


• Index• ICD 11 for

Mortality and Morbidity Statistics

• Specialty versions• Content model• Extension codes

ICD-11 Foundation – input from ICD-10 and derived classifications, links

Substances INN (=> ATC)

ICD-OCancer

External causes of injuryICECI

Terminologies, eg SNOMED

OrphanetICPC

ICHI dimensions (International Classification of Health Interventions)

ICF (Functioning)

ICD-10 Specialty versions(ICD-10MM, ICD-10 DA…)

ICD-10 national modifications (Australia, Canada, Germany,…)


Foundation Component & Tabular Lists of ICD–11

The Foundation Component

– is a multidimensional collection of all ICD entities.

– Entities can be diseases, disorders, injuries, external causes, signs and symptoms. Some entities may be very broad e.g. ‘injury of the arm’, others are more detailed, e.g. ‘laceration of the skin of the thumb.

– has the necessary information to use the entities to build a tabular list (a mono hierarchy in the style of a traditional statistical classification). E.g. includes information on where and how a certain entity is represented in a tabular list, whether it becomes a grouping, a category with a stem

code, or whether it is mentioned as an inclusion term in a particular category.


The ICD-11 Tabular lists

Tabular lists are subsets of the foundation component, that are:

• Fit for a particular purpose: reporting mortality,

morbidity, or other uses

• In a tabular list, entities of the foundation become

categories that are Jointly Exhaustive and Mutually

Exclusive of each other

• Each catergory is given a single parent

• Residual categories: Other (*.8) Unspecified (*.9)

generated for each linearizationExamples of ICD-11 Tabular lists ICD-11 Mortality and Morbidity Statistics (ICD-11 MMS)

ICD-11 Primary Care

Specialty tabulations

– Dermatology

– Oncology

– Mental Health

– Traditional Medicine

– …

National tabulations (CM, AM, CA, GM…)


Differences to ICD-10- Coding scheme

The chapter numbering:– Arabic numbers (not roman numerals)

The coding scheme for categories: – Minimum 4 characters

– 2 levels of subcategories

Coding scheme – A letter is always in the 2nd position to differentiate from ICD-10 codes

– No l,I (L,i); 0,O (Zero, o)

First character of code always relates to the chapter. Numbers 1-9 are used for the first nine chapters and letters are used for chapters 10 to 26

Residual categories use Y for other, Z for unspecified


Capturing detail of health information with ICD-10

Trained expert coders / Manual coding with complex rule base / Commercial coding software / interface terminology


ICD-11 capturing detail of health information

Reality 1:(individual detail)

Reality 2: (public health, clinical, adminstrative needs)

ICD-11 Categories

ICD-11 Index terms

Free Text (Diagnostic information)


ICD-11 Index terms

Entities and Synonyms under the “surface” include

• Extension codes, e.g.


OPTIONAL Extension codes – add all the detail you need, if you want

Type 1

Severity Temporality (course of the condition) Temporality (Time in life) Aetiology Anatomic detail Topology Anatomic location Histopathology (ICD-O) Biological Indicators Consciousness Substances External Causes detail Injury Specific detail Health Devices, Equipment and Supplies

(WHO Nomenclature of medical devices)

Type 2

Main Condition – Reason for encounter – Reason for admission – Main Resource Condition

Present on Admission – Developed after admission– Uncertain timing relative to admission

Provisional diagnosis

Diagnosis confirmed by… – Lab – Serology – Histology – Genetics – Imaging –– Unspecified means

Differential Diagnosis

Medicaments (WHO INN*)Chemicals

*International Nonproprietary Names: https://www.who.int/medicines/services/inn/en/


ICD-11 Index terms

Entities and Synonyms under the “surface” include

• categories in the ICD-11 MMS

– e.g. Hutchinson-Gilford syndrome under LD2B Syndromes with premature ageing appearance as a major feature

• Residual categories

– e.g. Capsular age-related cataract under 9B10.0Y Other specified age-related cataract


Title Primary Care MMS. Ophthalm.

Cataract code code code

Age-related cataract code code code

Cortical age-related cataract other other code

Nuclear age-related cataract other other code

Cataracta brunescens other other code

Nuclear sclerosis cataract other other code

Capsular and Subcapsular age-related cataract other other code

Capsular age-related cataract other other code

Anterior subcapsular polar age-related cataract other other code

Posterior subcapsular polar age-related cataract other other code

Incipient age-related cataract other other code

Coronary age-related cataract other code code

Punctate age-related cataract other code code

Water clefts other other code

Advanced or mature age-related cataract other other code

Mature age-related cataract other code code

Subtotal advanced or mature age-related cataract other other code

Advanced or mature age-related cataract, total cataract other other code

Morgagnian age-related cataract other other code

Calcified age-related cataract other other code

Combined forms of age-related cataract other other code

Example of a telescopic tabulations


ICD-11 index terms & URIs

http://id.who.int/icd/entity/1935092859




















































http://id.who.int/icd/entity/1959883044http://id.who.int/icd/entity/685093552http://id.who.int/icd/entity/1302232870

1C5C.111C5D.131C5.1Y1C5.1Z

Shoreline

Entity has a codegrouped into a category; has URI for recording, if desired

URIs are identifiers

– They are unique worldwide

They look like web site URLs

– http://id.who.int/icd/entity/127637236

Clear, familiar format

They are used as:

– identifiers for ICD-11 entities

– endpoint of the web services



ICD-11 Index terms includes local term variations

– Synonyms in English version

• e.g. end stage renal failure under GB61.5 Chronic kidney disease, stage 5

– Synonyms in Spanish version (upcoming)

• e.g. intento de autoeliminación under MB23.R Intento de suicidio


Compiling diagnostic term set for enhancement of ICD-11 index and ICD-FIT


Keeping clinical term

“Other specified“: not satisfactoryChoose the specific term, spigelian hernia, for the record

DD5Y Other specified hernias URI: http://id.who.int/icd/entity/1999215191 Spigelian Hernia

Health Record

DD5Y Spigelian Hernia


ICD-11 Coding Tool allows accurate coding of generic & specific diagnostic terms in multiple languages

Post-coordination combinations are automatically indexed for the following axes• Laterality• Course (acute /chronic )• Specific anatomy (when the value set has less

than 50 items)


ICD-11 coding

Code simple

Starting using ICD

Limited resources

Detail that is reliably reported

Use of the data

Code as much detail as you need

Patient safety systems

Device- or Substance safety

Research

Accident monitoring

Cancer registration

Resource allocation


Case with comminuted fracture of right humerus shaft

Code simple

NB52.4 Fracture of shaft of humerus

Code very detailede.g. for research

NB52.4 & XK9K & XJ1Z6

NB52.4 Fracture of shaft of humerus

XK9K Right

XJ1Z6 Comminuted fracture


Example: Stem code + stem code(s)

Type 2 diabetes mellitus with diabetic foot =

5A11 / BD54(5A11 Type 2 diabetes mellitus

BD54 Diabetic foot ulcer)


Simple search

Type a diagnostic statement into the Coding Tool

e.g. cancer of stomach

The Coding Tool will find the best match


Simple search


e.g. Osteoarthritis of right knee


Flexible search


e.g. splenic flexure colonic liposarcoma


Flexible search cont.

The Coding Tool now finds an almost exact match


Flexible search cont.postcoordination option for histopathology


Coding External causes using postcoordination


Coding External causes using postcoordination


The New Version of the ICD-11 Coding tool (cont.)


Browser and Coding toolhttps://icd.who.int

https://icd.who.int/


Authoring Tool(iCat)

ICD-11 repositoryDaily versions

ReleasesSnapshots

ICD-APIRESTFUL Web services

ICD Search Indexmultiple versions

multiple languages

ICD-11 Browser

ICD-11 Coding Tool

Proposal Mechanism

Translation ToolICD-11 DatabaseProposals

Translations

Print versions

ICD-11 Tooling environment


ICD-11 Translation Tool

Makes ICD-11 translation easier, faster and better through

– translation memory (use of existing ICD-10 translations)

– multiple translators can work simultaneously

– automatic update of structural changes in translation

– Notification and track change function for content changes

– commenting on the translations

Ongoing translation: 14 languages including official WHO languages


Multilingual browsing with ICD-11


How software talks to ICD-11?ICD API (Application-Programming Interface) https://icd.who.int/icdapi

Access to ICD-11 categories (17.000)

Access to ICD-11 index terms (currently over 105.000 medical diagnostic terms)

Access to and index-based searchalgorithm (currently interpret more than 1,6 million terms)

Easy to deploy (online & offline) using container DOCKER software

Easy to update due to ICD-11 URIs

https://icd.who.int/icdapi


ICD-11 Coding training and self-evaluation tool (ICDfit) Analytics features

• Coders get feedback how coded they coded each diagnostics statement

• Coders will get summary score indicating their coding accuracy & timing (performance)

• Coders can compare their resultswith their peers (ranking)

• Member States & WHO can assess coding quality, translations and improve classification & tooling


Module 2 (n=30):

– 27 terms -> coding accuracy 90% or higher

Conclusion: Good to very ICD-11 coding results with basic training


ICD-11 Implementation package

Browser, Coding tool, APIs

Reference Guide (user manual - online)

Transition guide

Translation tool

Mapping between ICD-11 and ICD-10

ICD-11 Coding training and self-evaluation tool (ICDfit)

ICD-11 e-learning tool (in preparation)

ICD-11 AnaCoD 3 (in preparation)


ICD-11 Implementation preparation

Jan/Feb 2019: ICD-11 training workshops with 70 countries from all WHO Regions

May 2019: ICD-11 adopted by 72nd World Health Assembly – ICD-11 will come into effect 1. Jan 2022

Global Implementation Plan – Phase 1: 2019-2021: Enable countries to become early adopter of ICD-11 by

2021 • Country pilot projects on ICD-11 API integration in EMR software

and/or national reporting systems (e.g. DHIS-2)• Guidance and capacity building to develop country roadmap for ICD-

11 implementation• Translation support• Development and enhancement of ICD-11 Implementation package

• Statistical impact assessment including linkage with selected targets and indicators GPW13 impact framework

• Build-up and strengthen WHO internal competency and capacity for ICD-11

• WHO FIC Networks engagement and scale-up Member State engagement in ICD-11 maintenance

– Phase 2: 2022-2032: Scale-up implementation & routine maintenance


The Family – integrated health information

Reference

Classifications

Derived

Statistical

Classifications

and

Tabulations R

ela

ted

Cla

ssif

icati

on

s

International

Classification of

Diseases (ICD)

International

Classification of

Functioning,

Disability and

Health (ICF)

International

Classification of

Health

Interventions

(ICHI)

Foundation

Sharedterminologies

VERSIOND-2

Documents

International Statistical Classification of Diseases and ... CARINFONET.pdf · 7 ICD-11 intro / 3rd CARINFONET Steering Group Meeting / Tashkent, Uzbekistan, 18 –20 June 2019 International